H.R. 3069 — Medicare for All Act

This section establishes the Medicare for All Program, a national health insurance program that provides comprehensive protection against the costs of health care and health-related services in accordance with standards specified in or established under this Act.

This section entitles every U.S. resident to health care benefits under the Act and directs the Secretary to promulgate residency criteria. It further authorizes the Secretary to extend eligibility to other individuals present in the U.S., with regulations to ensure universal access to health care while prohibiting travel to the U.S. solely to obtain such benefits.

This section prohibits discrimination on the basis of race, color, national origin, age, disability, marital status, citizenship status, primary language use, genetic conditions, previous or existing medical conditions, religion, or sex (including sex stereotyping, gender identity, sexual orientation, and pregnancy and related medical conditions, including termination of pregnancy) in the program established under this Act. The prohibition applies to exclusion from participation, denial or reduction of benefits, or other discrimination by participating providers or any entity conducting, administering, or funding a health program or activity pursuant to the Act, including contracts of insurance (except as expressly authorized for eligibility standards under section 102). This section directs the Secretary to establish procedures for adjudicating administrative complaints alleging violations and authorizes any aggrieved person to file suit in U.S. district court concurrently with administrative remedies, with courts authorized to award compensatory and punitive damages, declaratory or injunctive relief, attorneys' fees and costs, or other appropriate relief. This section specifies that its provisions do not limit rights, remedies, or standards under Section 1557 of the Patient Protection and Affordable Care Act (42 U.S.C. 18116), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), Title VII of the Civil Rights Act of 1964 (42 U.S.C. 2000e et seq.), Title IX of the Education Amendments of 1972 (20 U.S.C. 1681 et seq.), Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), or the Age Discrimination Act of 1975 (42 U.S.C. 611 et seq.), nor do they supersede state laws providing additional protections against such discrimination.

This section directs the Secretary to establish an enrollment mechanism for individuals eligible for benefits under the Act that (1) provides for automatic enrollment at birth in the United States or upon establishing U.S. residency; (2) enrolls all eligible individuals as of the dates specified in section 106; and (3) enrolls individuals made eligible under section 102(b). The section further requires issuance of a Universal Medicare card to each enrollee for identification and claims processing, which must not include the individual's Social Security number.

This section establishes the effective date for benefits under the Act as two years after enactment for items and services furnished, except that benefits are available one year after enactment for eligible individuals who have not yet attained age 19 or have attained age 55 as of that date. Eligible individuals may opt to continue coverage under section 901, private health insurance, or subtitle A of title X until the two-year date.

This section prohibits, effective on the date specified in section 106(a), (1) private health insurers from selling health insurance coverage that duplicates benefits provided under this Act, and (2) employers from providing duplicative benefits to employees, former employees, or their dependents. It specifies that health insurance for additional benefits not covered under this Act remains permissible.

This section entitles individuals enrolled for benefits under this Act to payment by the Secretary for a comprehensive package of 18 categories of medically necessary or appropriate health services, including hospital care, ambulatory and primary/preventive services, prescription drugs, mental health and substance use treatment, comprehensive reproductive and gender-affirming care, long-term services and supports, and telehealth (among others). It incorporates Medicaid's early and periodic screening, diagnostic, and treatment (EPSDT) services for children and requires transportation for persons with disabilities, older individuals with functional limitations, or low-income individuals. The section further (1) requires the Secretary to annually evaluate and recommend improvements to the benefits package to Congress (without recommending elimination of any benefit); (2) mandates annual hearings by specified House committees on those recommendations; (3) directs the Secretary to consult experts on including complementary and integrative medicine practices; and (4) authorizes states to provide additional benefits at state expense.

This section prohibits (1) cost-sharing requirements, including deductibles, coinsurance, copayments, or similar charges, for any benefits provided under this Act; (2) balance billing by providers to enrolled individuals for covered services; and (3) prior authorization determinations or step therapy protocols for such benefits.

This section excludes benefits under the Act for items and services that do not meet standards developed by the Secretary pursuant to section 201(a). It requires the Secretary to make national coverage determinations for experimental items, services, and drugs consistent with Medicare's national coverage determination process (42 U.S.C. 1395ff(f)(1)(B)) and establishes an appeals process modeled on Medicare's appeals procedures (42 U.S.C. 1395ff). For items and services subject to a recognized national practice guideline, such items and services are deemed to meet the standards if furnished in accordance with the guideline (with exceptions for deviations based on a provider's professional judgment, the patient's best interest, and the patient's wishes). It further authorizes a patient's treating physician or other qualified health care professional to override such standards or guidelines if, in their professional judgment, the override is medically necessary and appropriate, in the patient's best interest, and consistent with the patient's wishes.

This section establishes an entitlement to long-term services and supports (LTSS) for individuals enrolled under this Act who have medically determinable physical or mental conditions causing functional limitations in performing activities of daily living (ADLs)—such as eating, toileting, grooming, dressing, bathing, and transferring—or instrumental ADLs (IADLs)—such as meal preparation, managing finances, shopping, household chores, communicating, and community travel and participation. LTSS must be tailored to individual needs via assessment and defined by the Secretary to (1) include long-term nursing services in institutional or home- and community-based settings; (2) cover a broad spectrum of HCBS and non-institutional care; (3) meet enrollees' physical, mental, and social needs while maximizing autonomy, civic, social, and economic participation; (4) prioritize HCBS over institutionalization; (5) ensure HCBS—regardless of disability type, service need, or age—unless an enrollee elects otherwise; (6) enable services in the least restrictive, most integrated setting; (7) support independence, self-determination, and dignity; (8) ensure equal quality and geographic accessibility; and (9) allow self-direction by enrollees or chosen care coordinators. (As background, HCBS are non-institutional alternatives to nursing home care, as authorized under Medicaid waiver provisions in SSA §1915(c), (d), (i), and (k) (42 U.S.C. §1396n).) The Secretary must consult an advisory commission—including people with disabilities and older adults using LTSS, their representatives, diverse population groups, providers (including family caregivers), disability rights organizations, labor, academics, and researchers—in developing implementing regulations. Budgeting and payments follow title VI of this Act. The section defines LTSS, ADLs, IADLs, and HCBS (incorporating 42 C.F.R. §§441.530 and 441.710).

This section establishes requirements for individuals and entities to qualify as providers of covered items or services under the Act, including qualification under section 302, filing a participation agreement with the Secretary, and compliance with Medicare provider standards under section 1866 of the Social Security Act (42 U.S.C. 1395cc). The participation agreement must include provider commitments to (1) furnish items and services without discrimination to eligible persons (except those outside the provider's normal practice); (2) make no unauthorized charges to enrolled individuals; (3) provide information required for quality review, payment verification, studies, and other purposes under uniform reporting standards established in section 401(b)(1); (4) refrain from employing or using providers terminated for cause (absent case-by-case Secretary authorization); (5) submit fee-for-service bills and documentation within 30 days of service; (6) submit specified information and quarterly data within 30 days for institutional providers paid under section 611; (7) disclose coding systems used for payments or data collection and refrain from using them for financial incentives, proprietary purposes, or to increase payments; (8) comply with provider ethics and reporting requirements; and (9) prohibit non-individual providers' board members, executives, or administrators from receiving compensation, owning stock or other financial interests in, or serving on boards of entities contracting with or supplying the provider. This section further imposes a duty of ethics on providers to act exclusively in patients' interests under the applicable standard of care, with the Secretary required to issue reporting rules for compliance, prohibit bonuses, incentives, profit-sharing, or compensation tied to patient utilization or others' financial outcomes for providers and their families, and bar providers or representatives from board service or financial ties to supplying entities. Participation agreements may be terminated by the Secretary for noncompliance (with notice and opportunity to cure unless immediate action is required for public health or safety), under section 411, or by the provider.

This section establishes qualifications for health care providers under the Act, requiring licensure or certification in the state where services are furnished, compliance with state law requirements, and applicable federal law. It disqualifies entities or providers that do not directly furnish items and services to individuals, including contractors and Medicare Advantage organizations that do not directly provide care plan services. The section directs the Secretary to establish, evaluate, and update national minimum quality standards for institutional providers (mirroring Medicare standards) and individual practitioners—including safe nurse-to-patient staffing ratios, personnel training and competence, service comprehensiveness and continuity, patient access and preferences, and performance measures—with states able to impose additional standards and a transition period for new requirements; it further prohibits disqualification of certified providers for reasons unrelated to their ability to furnish services. Federal providers qualified under the Department of Veterans Affairs, Indian Health Service, or TRICARE direct care are deemed qualified for eligible individuals.

This section establishes rules governing private contracts between providers and individuals eligible for benefits under this Act, applicable beginning two years after the date of enactment. For participating providers (i.e., those with an agreement under section 301): (1) prohibits billing or private contracts for covered items and services provided to eligible individuals; (2) permits private contracts for noncovered items and services provided to eligible individuals only if the item or service is not payable under the Act, the provider receives no direct or indirect reimbursement under the Act, the contract is written, signed prior to furnishing (and not during an emergency), and clearly discloses patient responsibility for payment with no reimbursement or charge limits available under the Act, and the provider files an affidavit with the Secretary within 10 days of the first such contract stating no claims will be submitted under the Act; (3) authorizes enforcement for knowing and willful violations, including voiding the contract, no payments under the Act for any items or services furnished by the provider for two years from affidavit signing, and remittance of any such payments received; and (4) permits unrestricted private contracts with ineligible individuals. For nonparticipating providers: (1) permits private contracts for covered items and services provided to eligible individuals only if the contract is written, signed prior to furnishing (and not during an emergency), discloses the right to covered services from participating providers, patient responsibility for payment with no reimbursement or charge limits under the Act, and the provider files an affidavit stating no claims will be submitted under the Act; and (2) permits unrestricted private contracts with ineligible individuals.

This section requires the Center for Clinical Standards and Quality of the Centers for Medicare & Medicaid Services (CMS) (referred to in this title as the “Center”)—or another agency designated by the Secretary of Health and Human Services—to implement and evaluate all standards and quality measures under the Act, in coordination with the Agency for Healthcare Research and Quality and other Department of Health and Human Services offices. The Center must (1) review and evaluate practice guidelines developed under part B of title IX of the Public Health Service Act to determine recognition as national practice guidelines under section 203(c); (2) review standards of quality, performance measures, and medical review criteria under that part to assess appropriateness for health care quality reviews (prohibiting disability-discriminatory mechanisms in value or cost-effectiveness assessments) based on evidentiary basis, validity, reliability, and feasibility; (3) adopt methodologies for profiling health care professionals’ practice patterns and identifying outliers; (4) develop minimum competence criteria for entities conducting external quality reviews in administrative regions, requiring administrative independence, no financial incentives favoring specific practices, and national consistency through coordination and reporting; and (5) submit an annual report to the Secretary on outcomes research and practice guideline findings potentially affecting coverage determinations under section 401(a)(1)(G).

This section directs the Center to evaluate approaches for collecting data on health care disparities based on race, ethnicity, national origin, primary language use, age, disability, sex (including gender identity and sexual orientation), geography, or socioeconomic status, in conjunction with existing quality reporting requirements under the Act and considering patient privacy, administrative burdens on providers, and data improvements. It requires the Center to submit to Congress and the Secretary (1) a report on this evaluation not later than 18 months after benefits first become available under section 106(a), identifying approaches for such data collection and evaluation under the Medicare for All Program and recommending strategies for reporting quality measures by disparity category; and (2) subsequent reports on data analyses with recommendations for improving disparity identification, not later than four years after the initial report and every four years thereafter. Finally, the section requires the Secretary to implement the approaches identified in the initial report not later than two years after such benefits first become available.

This section establishes the Universal Medicare Trust Fund, to be financed by gifts and bequests; deposits and appropriations as provided in this Act; and, for fiscal years beginning with the fiscal year that includes the date benefits first become available under section 106, (1) 100% of net revenue increases attributable to amendments made by sections 801 and 902; and (2) in the initial fiscal year containing January 1 of the first year after enactment, an amount equal to the prior fiscal year's aggregate appropriations (increased by the consumer price index for all urban consumers) for Medicare under title XVIII of the Social Security Act (excluding premiums), Medicaid under title XIX, the Federal Employees Health Benefits program, TRICARE purchased care (excluding overseas), maternal and child health services under title V, vocational rehabilitation, certain Public Health Service Act programs, and other federal health programs identified by the Secretary of Health and Human Services in consultation with the Secretary of the Treasury; with subsequent annual amounts equal to the prior year's appropriation adjusted for this Act's cost reductions, consumer price index changes, and other factors determined by the Secretary. The section further (1) exempts Trust Fund monies from preexisting law restricting federal funds for reproductive health services; (2) applies subsections (b) through (i) of section 1817 of the Social Security Act (governing the Federal Hospital Insurance Trust Fund) to the new fund, with the Secretary serving as the Board of Trustees; and (3) directs transfer to the new fund of any remaining balances in the Federal Hospital Insurance or Federal Supplementary Medical Insurance Trust Funds after payment of all Medicare Part A and Part B claims.

This section amends the Employee Retirement Income Security Act of 1974 (ERISA) (1) to add new section 522 to part 5 of subtitle B of title I, prohibiting any employee benefit plan from providing benefits duplicative of payments under the Medicare for All Act, except that workers' compensation carriers must reimburse the Medicare for All Program for the cost of workers' compensation services (i.e., comprehensive medical benefits for work-related injuries and illnesses, including rehabilitation and long-term care); and (2) to revise the exception in ERISA section 4(b)(3) for plans maintained solely to comply with workers' compensation, unemployment compensation, or disability insurance laws by making it subject to the new reimbursement requirement. (Thus, workers' compensation plans remain exempt from most ERISA requirements but must reimburse the Medicare for All Program for covered services.) This section also makes a conforming clerical amendment to ERISA's table of contents.

This section limits the applicability of Part 6 of ERISA (i.e., continuation coverage requirements such as COBRA, which require group health plans to offer temporary coverage to employees and dependents after certain qualifying events) to only those employee health benefit plans that do not duplicate payments for items or services payable under the Medicare for All Act. It also makes a conforming amendment to ERISA Section 601 (29 U.S.C. 1161) to codify this limitation. (Thus, group health plans duplicating Medicare for All coverage are exempt from these requirements.)

This section terminates eligibility for Medicare (Title XVIII of the Social Security Act), Medicaid (Title XIX), State Children's Health Insurance Program (Title XXI), Federal Employees Health Benefits (chapter 89, title 5, U.S. Code), and TRICARE purchased care benefits for items or services furnished to individuals eligible under this Act beginning two years after enactment, subject to exceptions. Exceptions include (1) continuation of benefits under those programs for inpatient hospital and extended care services during a continuous period of stay that began before the effective date and had not ended; (2) continuation of all school-related health programs, centers, initiatives, services, or activities under Medicaid or CHIP as of January 1, 2019, under the Medicare for All program; (3) no effect on TRICARE direct care at uniformed services facilities or TRICARE Overseas purchased care benefits for eligible individuals located in overseas regions; and (4) no effect on veterans' medical benefits under title 38, U.S. Code, or Indian Health Service benefits, with no reevaluation of the Indian Health Service absent tribal consultation.

This section terminates the Federal and State Exchanges (i.e., health insurance Marketplaces) established under title I of the Patient Protection and Affordable Care Act effective two years after enactment. (Thus, any other provision of law relying on participation in or enrollment through such Exchanges—including premium tax credits and other subsidies under the Internal Revenue Code—ceases to have force or effect.)

This section terminates specified Medicare pay-for-performance and value-based purchasing programs effective on the date specified in section 106(a), including (1) the Merit-based Incentive Payment System under SSA section 1848(q); (2) physician incentives for meaningful use of certified EHR technology under SSA section 1848(a)(7); (3) incentives for adoption and meaningful use of certified EHR technology under SSA section 1848(o); and (4) alternative payment models under SSA section 1833(z). The section also terminates programs established by specified sections of the Patient Protection and Affordable Care Act, including (A) adult health quality measures (sec. 2701); (B) payment adjustments for health care-acquired conditions (sec. 2702); (C) pediatric accountable care organization demonstration projects (sec. 2706); (D) incentive payments for quality reporting (sec. 3002(b)); (E) hospital value-based purchasing (sec. 3001(a)); (F) value-based purchasing for skilled nursing facilities and home health agencies (sec. 3006); (G) value-based payment modifier under the physician fee schedule (sec. 3007); (H) payment adjustments for health care-acquired conditions (sec. 3008); (I) Medicare shared savings program (sec. 3022); (J) national pilot program on payment bundling (sec. 3023); (K) independence at home demonstration program (sec. 3024); (L) hospital readmissions reduction program (sec. 3025); and (M) plans for value-based purchasing for ambulatory surgical centers (sec. 10301). (Thus, any other provision of law relying on participation in or enrollment in these programs ceases to have force or effect, and Medicare provider payments will no longer include these performance-based adjustments.)

This section establishes definitions for terms used in the Act, including “global budget” (i.e., a payment negotiated between an institutional provider and as described in section 611(b)); “group practice,” “individual provider” (i.e., a supplier), and “provider” (adopting definitions from specified sections of the Social Security Act); “institutional provider” (i.e., providers of services, hospitals, psychiatric hospitals, rehabilitation hospitals, long-term care hospitals, and independent dialysis or end-stage renal disease facilities, as defined in specified Social Security Act provisions and regulations); “medically necessary or appropriate” (i.e., health care items and services needed to prevent, diagnose, or treat an illness, injury, condition, or disease, as determined by the treating physician or health care professional consistent with state law and Secretary standards); “Secretary” (i.e., Secretary of Health and Human Services); “State” and “United States” (i.e., each including the District of Columbia and U.S. territories); and TRICARE terms (adopting or specifying meanings from 10 U.S.C. §§101 and 1072).

This section establishes rules of construction for the Act's interaction with state and local laws, authorizing states and local governments to impose additional standards on eligibility, benefits, and minimum provider standards only if such standards (1) provide equal or greater eligibility than under the Act; (2) provide equal or greater in-person access to benefits; (3) do not reduce access to benefits; (4) allow effective exercise of professional judgment by physicians or other health care professionals; and (5) are otherwise consistent with the Act. The section further (1) preserves state licensing, practice, and educational laws for health care professionals and providers; (2) preserves employee and employer rights, privileges, remedies, and obligations under federal or state law or collective bargaining agreements; and (3) prohibits states from barring certified providers of items and services under section 201(a)(7) from program participation except based on their ability to provide such services.

This section prohibits Federal and State law enforcement officials and employees from using any funds, facilities, property, equipment, or personnel provided under this Act to investigate, enforce, or assist in enforcing any criminal, civil, or administrative violation or warrant related to a federal registration requirement based on religion, national origin, ethnicity, immigration status, or other protected category.